PRESUMPTIVE FERTILITY AND FETOCONSCIOUSNESS: THE IDEOLOGICAL FORMATION OF ‘THE FEMALE PATIENT OF REPRODUCTIVE AGE’ A Thesis Submitted to the Temple University Graduate Board In Partial Fulfillment of the Requirements for the Degree MASTER OF ARTS by Emily S. Kirchner May 2017 Thesis Approvals: Nora L. Jones, PhD, Thesis Advisor, Center for Bioethics, Urban Health, and Policy i ABSTRACT Presumptive fertility is an ideology that leads us to treat not only pregnant women, but all female patients of reproductive age, with the presumption that they could be pregnant. This preoccupation with the possibility that a woman could be pregnant compels medical and social interventions that have adverse consequences on women’s lived experiences. It is important to pause now to examine this ideology. Despite our social realities -- there is a patient centered care movement in medical practice, American women are delaying and forgoing childbearing, abortion is safe and legal -- there is still a powerful medical and social process that subjugates womens’ bodies and lived experiences to their potential of being a mother. Fetoconsciousness, preoccupation with the fetus or hypothetical, not-yet-conceived, fetus privileges its potential embodiment over its mother’s reality. As a set of values that influence our beliefs, attitudes, and behaviors, the ideology of presumptive fertility is contextualized, critiqued, and challenged. ii TABLE OF CONTENTS ABSTRACT………………………………………………………………………………ii CHAPTER 1: INTRODUCTION…….….……………...……………………………...…1 CHAPTER 2: TRACING PRESUMPTIVE FERTILITY THROUGH MEDICAL HISTORY…………………………………………………………………………………5 The Evolution of American Obstetric Care…………………………………….…5 Thalidomide: From Mothers to Threats…………………………………….……..8 Rubella: From Pregnant Bodies to Female Patients of Reproductive Age…...….10 The Evolution of American Abortion…………………………………………....12 The Pill, Roe, and Amnio……………..……………………………..…………...16 Fetal Alcohol Syndrome: From Threats to Criminals…………...……...………..18 CHAPTER 3: THE PERSONAL IS POLITICAL: EXPERIENCES WITH PRESUMPTIVE FERTILITY……………………………………………...……………22 CHAPTER 4: MATERNAL FETAL RELATIONSHIPS IN A CLASSICAL BIOETHICS FRAMEWORK……………………………………………………………28 CHAPTER 5: ALTERNATIVES TO PRESUMPTIVE FERTILITY: THE HARRIS MODEL…………………………………………………………………………….……32 CHAPTER 6: CONCLUSION….…………………………………….…………………35 BIBLIOGRAPHY………………………………………………………………..………40 APPENDIX: VISUAL REPRESENTATIONS OF PRESUMPTIVE FERTILITY….…43 iii CHAPTER 1: INTRODUCTION In 2016, decades after oral contraceptives became available, a generation past Roe v. Wade, and years into the trend of American women delaying or forgoing childbearing, two news stories captivated the public’s attention and proved that we were more fetoconscious than ever. On February 2, 2016, the Centers for Disease Control and Prevention (CDC) released a Vital Signs report warning over three million women that they put “a developing baby at risk” if they were sexually active, not using birth control, and consuming alcohol (See Appendix). According to CDC Principal Deputy Director Anne Schuchat, M.D.: “Alcohol can permanently harm a developing baby before a woman knows she is pregnant. About half of all pregnancies in the United States are unplanned, and even if planned, most women won’t know they are pregnant for the first month or so, when they might still be drinking. The risk is real. Why take the chance?”1 Immediate backlash came from women who felt this advice was impractical. Writing for Jezebel, Jia Tolentino, then a deputy editor for the feminist publication, said the recommendation “suggests the same old idea that all women are either future, current, 2 past or broken incubators, and that is their body’s primary use.” The CDC’s warning for women came in the midst of ever more panicked media coverage of the 2015-2016 Zika virus outbreak in South and Central America. Because Zika virus threatened a generation of children with microcephaly, access to birth control, abortion, and prenatal care became heightened global concerns. But our worry was not 1 “Alcohol and Pregnancy,” Centers for Disease Control and Prevention, February 2, 2016, accessed April 16, 2017, https://www.cdc.gov/vitalsigns/fasd/idex.html 2 Jia Tolentino “An Unrealistic Warning From the CDC to Women: Don’t Drink Unless You’re Using Birth Control,” Jezebel, February 3, 2016, accessed April 16, 2017, http://jezebel.com/an-unrealistic- warning-from-the-cdc-to-women-dont-drin-1756823580 1 only for the women and infants living in Brazil. The CDC issued travel advisories (the first ever in their history) directed at pregnant or potentially pregnant women.3 As research emerged slowly about the virus, limited information was available--when was the virus most dangerous? How long after infection did it remain in the body? What role did paternal versus maternal infection and transmission play? None of these questions appeared on the signage displayed in airports (See Appendix). Together, these events signal an era of unprecedented fetoconsciousness and presumptive fertility. I coin the term ‘fetoconsciousness’ to refer to the preoccupation with the fetus or the hypothetical, not yet conceived, fetus. When the nation’s health protection agency warns every traveler in every airport about the risks of Zika virus in pregnancy, but does not warn every traveler in every airport to wash their hands, for example, fetoconsciousness is at work. The CDC’s recent displays of fetoconsciousness reflect a larger ideology, which I call presumptive fertility. This ideology asks us to consider every female patient of reproductive age as heterosexually active and fertile, removed from the individualized contexts of their life, their sexuality, and their own reproductive goals. Medical technology and public health advances as well as our values surrounding pregnancy and motherhood have created our current medico-social-legal landscape. And in this presumptive fertility landscape, fetoconsciouness has become the status quo. An emergency room physician instructed me: “Everyone needs a pregnancy test. As far as I’m concerned it should be the fifth vital sign.” Of course this doctor didn’t mean everyone. He meant women. To be more specific, he meant heterosexually active, 3 “CDC Newsroom,” Centers for Disease Control and Prevention, January 15, 2016, accessed April 16, 2017, https://www.cdc.gov/media/releases/2016/s0315-zika-virus-travel.html. 2 cisgender women between menarche and menopause. But by saying “everyone,” he betrays deeper meanings. “Everyone” refers to the potential positive result of the pregnancy test and the physician’s responsibility for that potentiality, too. “Everyone needs a pregnancy test” also refers to society. Everyone is interested in protections for the good of all, people who are here and people who are merely hypothetical. Presumptive fertility is at play in medical decisions, hospital protocols, and governmental actions because of fetoconscious bias. If perfectly produced babies are a social good that can be achieved with appropriate behaviors performed by pregnant women, then presumptive fertility includes the practices deployed by institutions monitoring and controlling both pregnant patients as well as those patients that may become pregnant. Consider these scenarios: • Requiring pregnancy testing before radiologic imaging studies • Arresting pregnant women found to be using drugs or alcohol • Forced cesarean sections for pregnant women who do not consent • The CDC’s advice to sexually active women regarding alcohol • Travel warnings for Zika virus endemic areas Presumptive fertility has become a normative ideology. It is critical to understand how it came to be, why it is unethical and dangerous, and what the alternatives are. The first section of this thesis has explored and defined fetoconsciousness and presumptive fertility. Next, I will trace the evolution of medical care for pregnant women, a medical history which includes medical authority over both childbirth and abortion. In particular, I will focus on three events that have enabled presumptive fertility: the thalidomide crisis, the rubella epidemic, and the discovery of fetal alcohol syndrome. 3 With this historical background, I will describe real examples of presumptive fertility from personal experience as a patient and a medical student. To understand why presumptive fertility is unethical, I will contextualize fetoconsciousness in a classical bioethical framework and suggest an alternative ethical model for maternal fetal relationships. Finally, I will suggest how we can dismantle presumptive fertility in medical education and medical practice. 4 CHAPTER 2: TRACING PRESUMPTIVE FERTILITY THROUGH MEDICAL HISTORY To understand how presumptive fertility came to be, we must ground our history in the history of medically managing pregnancy, childbirth, and abortion. This history has six main trajectories that I will explore. The first is the shift in authority over care for pregnancy and childbearing from women’s social networks to medical doctors. I will explore the thalidomide crisis, which forever altered our understanding of the maternal fetal relationship and cemented our view of pregnant bodies as potential threats. Almost immediately after the thalidomide tragedy, a rubella epidemic widened the focus of fetoconscious medical providers, representing a shift in medical control not only over pregnant women but over all female patients of reproductive age. I will examine the history of American abortion and in particular, therapeutic